Blue Shield to significantly cut reimbursement of E/M services billed with modifier 25 and will no longer pay consult codes

May 08, 2024

Blue Shield of California recently notified physicians of two upcoming changes to the payor’s policies. Effective July 14, 2024, Blue Shield will no longer reimburse for face-to-face consultation services (CPT codes 99242-99245 or 99252-99255). Additionally, the notice states it is changing its Global Surgical Period Payment Policy, which will significantly reduce reimbursement for evaluation and management (E/M) services billed with modifier 25.    

Consultation Codes

Blue Shield is the latest payor to announce it will no longer reimburse consultation services. Consultation services, including telehealth consults, previously represented by CPT codes 99242-99245 and 99252-99255 will need to be billed utilizing the appropriate evaluation and management (E/M) procedure code that describes the office visit, hospital care, or nursing facility care. Medicare stopped recognizing and paying for consultation codes in 2010. 

Modifier 25

The notice also states Blue Shield will reduce reimbursement of certain office and other outpatient visit E/M services (CPT codes 92002, 92004, 92012, 92014 and 99201-99215) by 50% when appended with modifier 25 and billed with a minor surgical procedure code (0- or 10-day global period) by the same physician or physicians of the same group. According to Blue Shield, the rationale for the decision is to “no longer reimburse for the practice expense component twice, once for the E/M service, and again for the global day code.” The California Medical Association (CMA) believes this rationale to be a misunderstanding of the code valuation process and this policy change will create a disincentive for physicians to provide unscheduled services. 

CMA has reached out to Blue Shield to discuss our concerns with the adverse impacts the changes to its modifier 25 policy will have upon our physician members and is coordinating with the American Medical Association and other specialty organizations. 

Physicians with concerns or questions about the policy can contact Blue Shield Provider Services via live chat after logging in at blueshieldca.com/provider or by phone at (800) 541-6652. 

Contact: CMA’s Center for Economic Services at economicservices@cmadocs.org or (800) 786-4262. 


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